Wider Concerns of Older Cancer Patients 'Need Addressing'

Liam Davenport

June 02, 2018

CHICAGO — When a geriatric assessment (GA) is provided as part of routine care to oncologists who are treating elderly patients with cancer (>70 years), it allows them to have a higher-quality discussion of age-related health concerns and results in more tailored interventions, concludes a new US study.

"In oncology, we don't have a lot of time in the clinics," commented lead author Supriya Gupta Mohile, MD, the Wehrheim professor of medicine at the University of Rochester, New York. "We're very focused on the cancer and the treatment," and when patients go to see their oncologist, "they're thinking about their cancer."

The GA explores overall health as well as functional and performance status, and therefore "sort of provides permission for people to talk about [age-related concerns]," Mohile explained. It takes into account memory issues and problems with walking, as well as issues in the family life of the patients. As an illustration, she highlighted the example of a woman who has just been diagnosed with cancer having concerns about how she is now going to take care of her husband with dementia.

GA is a way of evaluating geriatric domains known to predict morbidity and mortality, including functional status, physical performance, comorbidities, cognition, and nutritional status.

It provides an opportunity for patients and caregivers, as well as oncologists, to have an "unclear understanding" of what could be relevant, and this "will lead to better decision making for treatment, and also to better care overall," she commented.

"As oncologists, we need to step away from focusing solely on the cancer, especially in older patients," she commented in a statement.

"While living longer is important, there are many non-cancer-related health issues that are as, if not more, important," she added.

Mohile was speaking here at American Society of Clinical Oncology (ASCO) 2018, at a press conference at which the study was highlighted.

A recent ASCO guideline underscored the importance of GA, making a series of recommendations on the practical assessment and management of vulnerabilities in older patients receiving chemotherapy.

However, although a GA has been shown to be both feasible and able to guide interventions known to improve outcomes in community-dwelling adults, only 20% of community oncologists use GAs in clinical practice.

Mohile and colleagues therefore instigated the Improving Communication in Older Cancer Patients and Their Caregivers (COACH) trial to determine whether providing a GA summary and recommendations for interventions would boost engagement over age-related patient concerns.

The cluster randomized controlled trial involved 542 patients aged at least 70 years with advanced solid tumors or lymphoma and at least one impaired GA domain, who were recruited from 31 practice sites.

All patients underwent a GA, which consisted of self-report assessments typically completed by patients in no more than 30 minutes and objective tests that took less than 10 minutes of practice staff time.

The tests were then scored, and an algorithm based on validated cutoffs was used to generate a summary of impairments and a list of proposed interventions tailored for each individual patient.

The patients were assigned either to an intervention group, in which the oncologist received the summary and interventions, or to a control group, in which the oncologist was not given the summary or interventions.

Mohile pointed out that in the intervention group, "the oncologist had complete control over what they did with" the summary and proposed interventions.

"We didn't say you have you have to do anything, we just provided the information and then the oncologist took that into the clinic visit and discussed it with the patient," she explained.

The clinic visits in both the intervention and control groups were recorded, and blinded coders assessed the number and quality of age-related discussions, as well as the plan for follow-up interventions.

Patients also underwent telephone surveys to determine their level of satisfaction.

The prevalence of impairments ranged from 93.5% for physical performance to 25.1% for psychological status, with 33.2% of patients found to have cognitive impairment. Moreover, 89.3% of patients had two or more impairments.

Increase in Discussions and Satisfaction

Providing oncologists with the GA summary and proposed interventions led to a significant increase in the number of age-related discussions, at 7.74 vs 4.24 in the control group, for a mean difference of 3.5 discussions (P < .0001).

It was also associated with significantly more higher-quality discussions, at 4.42 vs 2.47 in the control group and at a mean difference of 2.0 (P < .0001), as well as more interventions, at 3.08 vs 1.15 (mean difference, 1.9; P < .0001).

Patients in the intervention group were more likely to be satisfied with their physician–patient communication, at a mean increase of 1.12 points on the Health Care Climate Questionnaire (P = .01), which was maintained up to 3 months later.

Similar improvements were seen on a version of the questionnaire modified for age-related concerns (P = .02 between the intervention and control groups).

Mohile commented: "Both patients and their caregivers clearly want the oncologist to discuss age-related concerns. Our study showed that GA can help oncologists meet these needs for their older patients."

The results "lend further support to the new ASCO guideline, which recommends GA for all patients undergoing chemotherapy," she added.

The geriatric oncology community plans to partner with ASCO and other groups such as the Cancer and Aging Research Group to continue to support and help practices implement GA for their patients, she said.

Commenting on the findings, ASCO Expert Joshua A. Jones, MD, said it is a "very important study that is likely to have a direct impact on the care of our older patients with cancer."

"This shows, in a randomized fashion, that we can, with a simple intervention, improve communication about what's really important to older patients with cancer," he said.

Jones emphasized that there are interventions available that can be provided to patients and families, such as physical therapy and counseling, that help oncologists "provide the most appropriate care for these individuals."

Therefore, by using GA, "we can make sure that we are understanding what is most important to our patients and providing the right kind of care that they want."

Study coauthor William Dale, MD, PhD, Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope, Duarte, California, told Medscape Medical News that GAs are primarily used in three ways for patients with cancer.

One was is to examine the likelihood of having serious complications as a result of the chemotherapy or surgery; another is to determine what could be done before treatment to improve outcomes, such as physical therapy or dealing with an individual's social circumstances; and the third is to examine the patient's overall life expectancy aside from the cancer.

To be able to provide that information to oncologists, there has been a move away from comprehensive assessments that took an hour and a half to more efficient and formalized tools derived from the literature.

The aim was to be able to apply GAs not only to academic centers but also a community oncologist "who's seeing 30 patients a day, and honestly, we feel like we've boiled it down to its essence."

One example of where such assessments can aid in decision making is that of cognitive impairment.

"What if the person can't remember or is having cognitive issues, and you consent them for chemotherapy?" Dale asked. "None of us think that's the right thing to do."

He said that further studies are awaited to demonstrate that GAs make a difference to outcomes, "but one thing we do know is it changes people's decisions."

Dale pointed out that one issue that could stand in the way of GAs being more widely applied is that of reimbursement. "We get paid to give people stuff and do procedures," he said, "and get paid less to spend a lot of time talking of patients."

He believes that the reimbursement structures around value-based initiatives will need to be adjusted to "nudge people towards the right things," even though they are "less tangible and hard to pin down" than survival rates after chemotherapy.

This study received funding from the Patient Centered Outcomes Research Institute and the National Cancer Institute. Mohile reported having a consulting or advisory role with Seattle Genetics. One coauthor reported having a consulting or advisory role with GTx, Boehringer Ingelheim, On Q Health, Sanofi, OptumHealth, Pierian Biosciences, and MJH Healthcare Holdings LLC, and receiving research funding from GlaxoSmithKline, Celgene, and Novartis. Another coauthor reported receiving institutional research funding from Amgen. Another coauthor reported having a consulting or advisory role with AIM Specialty Health.

American Society of Clinical Oncology (ASCO) 2018: Abstract LBA10003. Presented June 3, 2018

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